Nelson_Pediatric Ophthalomology, 3e

10 2 Abnormalities Affecting the Eye as a Whole

■ After initial socket expansion during the first 5 years of life, the socket and pros thetic will require examination yearly. ● Surgical care ■ Because the foreshortening of the eyelids may limit the passage of a large conformer, a lateral canthotomy or cantholysis may be needed to increase the horizontal length of the palpebral fissure. Other methods to lengthen the eyelids may include skin, mucosal, or cartilage grafts. ■ Injectable calcium hydroxylapatite (Radiesse) is a semipermanent dermal filler that has been reported as a new, simple, cost-effective technique to treat volume deficiency in the anophthalmic orbit in adults. Augmentation is accomplished with serial injections of the filler until adequate volumization is achieved. The results have shown lasting effect in the orbit of ≥ 1 year. ■ The small bony cavity is a cosmetic de formity and may not allow proper fitting of a prosthesis. Therefore, surgery may be indicated for either of these problems. ■ Hydrogel (methyl methacrylate and N -vinylpyrrolidone) expanders are self-expanding hydrophilic expanders that are implanted in the orbital tissue in their dry, contracted state through a small incision. They are made from the same material as con tact lenses and scleral buckles. The implant gradually expands in size by osmotic absorp tion of surrounding tissue fluid. The benefit of this method is the controlled self-expansion, reducing the risk of tissue atrophy, without the need for repeat fittings or surgery. ■ Inflatable tissue expanders are used if con formers are not well tolerated or cannot be fit. The inflatable silicone expander is a dynamic implant composed of a bladder and injection port. The expander is surgically positioned deep in the orbit and fixated to the bone, usu ally in the periosteal space of the orbit, and the injection port is usually placed in the tempora lis fossa. The expander is filled with saline and gradually reinflated on a weekly or biweekly schedule. Compared with solid conformers,

inflatable expanders may allow more rapid and extensive expansion of the bony orbit, but injections may be painful for the patient. The inflated chamber can also exert significant pressure on the surrounding tissue, leading to tissue atrophy, erosions, or extrusion of the im plant. When the desired volume is achieved, the port and bladder need to be removed and replaced with a permanent implant. ■ Dermal fat grafting is a dynamic implant using biocompatible grafts that grows slowly over time and can be a good option to restore volume to the hypoplastic orbit. The graft is harvested from a second surgical site, typi cally the buttocks. However, the graft com patibility and growth can be variable. In some cases, the fat can atrophy. Rarely, the fat can hypertrophy, which necessitates debulking. ■ Orbitocranial advancement surgery is used for orbital expansion if conformers and expanders are unsuccessful. This method involves multiple osteotomies to divide the periocular bones and advancing them forward and outward with bone grafts and plates. Prognosis ● Severe cosmetic deformities can result from anophthalmia, especially if not treated early. Even with proper treatment, the results are often cosmetically suboptimal, with incom plete expansion of the orbit, malformations and immobility of the eyelids, and complete immobility of the ocular prosthesis. ● The patient may need considerable input and services from multiple pediatric specialists due to associated systemic abnormalities including hypothalamic-pituitary disturbances, develop mental delay, renal hypoplasia, and heart defects. ● Psychosocial issues caused by absence of an eye and facial disfigurement can result. Referral for psychological counseling may be indicated for these children. ● Early vision support services to help the child and family negotiate visual impairment and work to integrate the child into society and ready them for school.

Copyright © 2024 Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited.